This Week in HIV Research: The Yawning Post-Prison Care Gap

Within our data-examining crosshairs this week is an eclectic mix of good and bad news. We get a distressing reminder of how much work remains to link HIV-positive inmates to proper HIV care once they're released; a glimpse into the modest costs (but potentially critical need) of financial assistance for Americans eligible for pre-exposure prophylaxis (PrEP); an encouraging bird's-eye view of just how good we've gotten at viral suppression (generally speaking) in recent years; and a sobering example of how little progress we've made toward making HIV testing routine in emergency departments, 11 years after the CDC officially recommended it.

To beat HIV, you have to follow the science!

Few People Living With HIV Are Promptly Linked to Care After Leaving Jail or Prison

When inmates are released from Connecticut prisons or jails, only about one out of five is linked to HIV care within two weeks, an analysis published in The Lancet HIV showed.

Study authors integrated state-wide correctional and HIV surveillance databases in Connecticut for 2007 to 2014, examining post-release data on 1,350 inmates (many of whom were incarcerated more than once during the study period). They found that in only 21% of cases was a former inmate linked to care within 14 days of release. At the 30-day mark, that proportion improved to just 34%; it reached 61% by the 90-day point and 83% by the one-year mark. Transitional case management might help improve that linkage rate, they suggested.

The study further revealed that an inmate's odds of having an initial post-release viral load below 400 copies/mL generally fell the longer it took to be linked to care. Among those linked to care within 14 days, 73% had a viral load below 400 copies/mL; that percentage fell to 65% among those linked to care between 15 and 30 days, and fell further to 60% for those linked to care between 31 and 180 days. Among former inmates who were linked to care six months to one year after their release, only 40% had an initial viral load below 400 copies/mL.

In a related comment, doctors David Wohl and David Rosen pointed to underlying social determinants responsible for lack of care. "Recognition of these social factors, including mass incarceration itself, as being toxic and unacceptable will spur on the policy changes that are needed to bridge this tragic gap in HIV care," they concluded.

The U.S. Centers for Disease Control and Prevention estimates that 1.2 million people meet clinical indications for this form of HIV prevention. Of these, about 7,300 would require financial assistance for clinic visits as well as the cost of the drug itself. Another 86,300 (roughly 7%) only would need help paying for PrEP-related medical care. The analysis estimated an annual cost of US$208 million for these two groups, compared to the federal HIV budget of US$19.7 billion.

Only around 6% of those who could benefit from PrEP have been prescribed the medication, the researchers note. "At current rates of uptake, it will be some time before all persons in need of financial assistance are attempting to access PrEP services," they wrote.

Viral Suppression Occurs Much Sooner After Diagnosis Today Than It Did 10 Years Ago

Over the past decade, the median time between seroconversion and viral suppression dropped from more than four years to less than 10 months, a retrospective cohort study of men who have sex with men that was published in AIDS showed.

Study authors analyzed data on 437 men who were diagnosed at a Melbourne, Australia, clinic between 2007 and 2016. Once diagnosed, people achieved undetectable viral loads within a little over 3 months at the end of the study period; the corresponding number for the beginning of the period was almost two years.

Study authors attribute these changes to several factors: greater awareness of treatment as prevention, guideline changes to treat everyone upon diagnosis, and integrase inhibitor-based treatment regimens that lead to faster viral suppression. "If replicated across the community, this reduction in the period of infectiousness could be expected to have a substantial impact on HIV transmission and incidence," they concluded.

The number of HIV tests performed during emergency department (ED) visits or inpatient admissions increased only modestly in several urban U.S. hospitals despite an effort to offer routine HIV testing in these situations, the HPTN 065 study published in Clinical Infectious Diseases found.

Between 2011 and 2014, fewer than 15% of ED visits and fewer than a quarter of inpatient admissions in 16 hospitals in the Bronx, N.Y., and Washington, D.C., included an HIV test. Study authors noted, however, that these data underestimate the number of people tested, since one person may account for multiple ED visits and/or hospital admissions during the study period.

A substantial number of positive HIV tests were also seen among people who had been previously diagnosed with HIV. "Notwithstanding, repeat testing for those with a prior HIV-positive test is not without benefit," because it may engage people in HIV care, study authors explained.

The study authors noted that administrative processes within hospitals, local regulations and written consent requirements hampered implementation of universal testing practices.

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